UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

Laparoscopic Liver Resection
(Buell, JF et al 2009b). Prior to embarking upon beginning a program in laparoscopic liver
surgery, it is necessary to acquire experience with both advanced laparoscopy and open
hepatic surgery. These requirements have made the widespread adoption of laparoscopic
liver surgery appropriately slow. As advanced laparoscopy becomes an increasingly
important part of general surgery training programs, these prerequisites will become less of
a hurdle, with the expected more rapid acceptance of laparoscopic liver surgery.
After establishing the necessary expertise in laparoscopy and open hepatic surgery, the ideal
starting point is small, benign lesions in the periphery of the liver. Extensive use of hand
assistance is also critical in reducing the learning curve. Koffron has described the hybrid
technique, in which mobilization of the liver is performed laparoscopically, and
parenchymal transection is then performed in an open fashion through the hand port
incision (Koffron, AJ et al 2007). He has termed this approach “laparoscopic liver surgery
for everyone,” and we agree that this approach represents an ideal starting point for a
laparoscopic liver program.
Once comfortable with performing more limited resections, the next step in development is
the performance of major, anatomic resections. In this setting, the left lateral segmentectomy
is the ideal starting point. Although much attention is given to the parenchymal transection
phase, it should be noted that the greatest risk for vascular injury and subsequent
conversion to an open procedure is actually during the mobilization phase. The most
commonly injured vessel in this setting is the phrenic vein, which must be carefully
identified and avoided. Conversion, as we have emphasized previously, should not be
viewed as a failure or complication. Instead, the decision to convert to an open or hand
assisted procedure rather than continue with a potentially unsafe situation laparoscopically
is a mark of good surgical judgment.
Experience with resection of lesions located in the peripheral segments of the liver provides
a foundation of skills, including mobilization, transection, hemostasis, and laparoscopic
ultrasound. Once this fundamental skill set has been developed thoroughly, the surgeon is
then able to proceed to more difficult lesions. At this point, malignant and/or large lesions
located in the right and posterior segments of the liver can then be approached in the
culmination of programmatic development. We have found that facility with minor
resections can be achieved in 30 to 50 cases. More difficult resections such as formal
lobectomy and right posterior resection require an additional 60 to 80 cases to master. Thus,
the road to development of a laparoscopic liver resection program is long and often
arduous, but is highly rewarding to both the surgeon and the patient when properly
travelled.
6. Conclusion
Nearly 15 years after first being described, laparoscopic liver resection has been gradually
gaining acceptance in a number of centers worldwide. As the necessary skills in advanced
laparoscopy and hepatic surgery become more widespread, we anticipate that the further
adoption of laparoscopic liver resection will increase more rapidly. The maturation of long
term series have proven the oncologic adequacy of the laparoscopic approach in a variety of
settings. With the development of a greater number of surgeons who are proficient in
laparoscopic liver surgery, many more patients will benefit from decreased blood loss, less
postoperative pain, and shorter lengths of stay. From being a novel procedure practiced in
only a handful of centers worldwide, laparoscopic liver resection is now established as a
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